Background: Changes in the SEM
information about the work processes, labor categories, and toxic materials
used at a DOE site can change the outcome of an eligibility determination and are
typically the result of DOL’s research of previously un-reviewed site
documentation. DOE does not maintain a central document repository or index of
records applicable to each site, thereby inhibiting DOL’s research and data
collection efforts. Records for most sites, especially those that are no
longer operating, are typically spread among several Federal Records Centers and operating DOE sites. Furthermore, active DOE sites regularly generate new
documentation. As a result, the DOL SEM research team constantly reviews site
documentation as it is identified and adds it to the DOL SEM Library where
appropriate (it’s worth noting that information is also obtained from the
Haz-Map website).

Past
adjudication results may have been different if adjudication had been performed
using current SEM information. To ensure that such previously adjudicated
cases are reviewed with the latest and most complete SEM information, this
procedure has been developed. Using this procedure will result in the
post-adjudication review of cases where changes in the SEM diseases and disease
associations could affect the denial decision. As noted above, this procedure
is also applicable to Part E claims that are still in the process of being
reviewed.

On a
quarterly basis, Paragon provides DEEOIC with a report that describes the
changes made to the SEM database and the affected ICD-9 codes, by worksite,
during the previous three months. The DEEOIC SEM Coordinator reviews this
report and shares it with the Branch of ADP Systems (BAS) within 2 business
days. The BAS then generates a “Post Adjudication Report” within 5-10 business
days.

The
Post Adjudication Report generated by BAS has two components: a SEM Summary
Report and a SEM Detail Report. The SEM Summary Report gives
the total number of Part E Denials, based on a medical condition (ICD-9 match) identified
as a result of changes in the SEM. These
numbers are broken up by District Office, including the FAB. The SEM
Detail Report provides specific information on these cases by District
Office, claimant name, affected worksite, file number and the assigned Claims
Examiner. Using this information, the District Offices/FAB can ensure that each
denial decision that could be affected by the SEM changes can be reevaluated. For example, the SEM may list a new relationship
between a toxic material and an occupational disease (the procedure “Instruction
for Compiling and Entering Toxic Substance Information into the Site Exposure
Matrices (SEM) Database,” provides a detailed discussion of how toxic
materials are added to the SEM). Using the ICD-9 code of that disease,
District Office/FAB personnel can search its database of denied cases to
identify those cases with the same ICD-9 disease code. At each District
Office, those cases on the SEM Detail Report are assigned to a Claims
Examiner (at the District Director’s discretion) for review to determine if its
denial should be reevaluated. The Claims
Examiner uses the SEM to reevaluate the case using current information. After
reviewing the totality of evidence, this reevaluation may result in the case
being reopened and approved or, alternatively, there may be no change in the
existing denied status. Similarly, for cases that are in the process of being
reviewed, this procedure will assist the current Claims Examiner with the most
current information relative to the condition being evaluated. These actions
are to be controlled by the District Director and the data are to be utilized
at the discretion of the District Director and the FAB Manager.

DEEOIC
believes the above process provides each claimant whose case has been denied a
fair opportunity for reevaluation whenever new disease and disease-toxic
material association information is added to the SEM database.

Purpose: To provide a mechanism
for ensuring that previously denied cases have a way to be reopened based upon
new medical and toxicological data that have been added to the SEM database since
the cases’ initial adjudication. This plan is also applicable to cases that have
yet to be adjudicated that may be impacted by changes to the SEM. For example,
if an additional causative agent link is added for bladder cancer, personnel
will have a means of addressing this new piece of information. This plan is
part of an overall effort to maintain the quality of the DEEOIC program and to
be claimant-friendly in the review and ultimate adjudication of claims.

Applicability: All staff.

Actions:

Using SEM Pre/Post-Adjudication Reports:

Sometimes changes are made in SEM that may affect
the DOL adjudication decision of a closed or in-process claim. Specifically, a
denied case may need to be reevaluated because of a disease or disease/toxic
material association change in the SEM. The SEM changes affecting an
adjudication decision include the recognition of an occupational disease not
previously listed in the SEM, deletion of a previously accepted occupational
disease, or new toxic substance associations with existing occupational
diseases.

Two methods have been established to facilitate the District
Office/FAB’s review of cases, the first for denied adjudicated cases
where the ICD-9 is impacted by a change in the SEM and the second for
pre-adjudication (in-progress) cases:

1.Using
the Post-Adjudication Report: As noted above, this report has two parts, the SEM
Summary Report (covers all the District Offices and the FAB)and the
SEM Detail Report (provides detailed information, including case number,
work location, claims examiner, district office, etc.). The Post-Adjudication
Report is issued periodically by the National Office to identify those denied
Part Ecases that may be affected by a change
in the SEM health effect information (by ICD-9) during the prior quarter. Please
see Figures 1 through 16 (attachments) to assist in visualizing these steps. It’s
important to note that the District Directors, FAB managers and National Office
management will ultimately review and prioritize possible post-adjudication
file review by trends in the data fields.

a. Using the SEM Detail
Report, Select the “All” tab or a District Office to display those cases of
interest. Delete the first row of the spreadsheet, and then enable the Excel
Auto Filter feature for all remaining columns and rows of the spreadsheet.

b. In the “ICD-9 CD” column
click on the drop-down arrow and select the ICD-9 Code of interest. The list
of those cases potentially affected by a change in the SEM is returned.

c. In the “Worksite ID”
column, click on the drop-down arrow and select the number of the site of
interest. The resulting list indicates those cases for the selected site that potentially
need to be reevaluated using current SEM information.

d. Using information in the “Case
Number” and “LOC” (case location) retrieve the case file for the case of
interest (for Privacy Act reasons, the case numbers have been suppressed in the
attached figures).

e. For only the
health effect in Step 2, repeat the applicable SEM searches. Section 4 of
chapter E-500 of the procedure manual provides guidance on using the SEM to
evaluate a claim.

(1) If the SEM indicates
that none of the claimant’s potential exposures is related to the health effect
then the Claims Examiner documents this information, inserts this documentation
in the case file, and returns the case file to storage.

(2) If the SEM indicates
that the worker may have been exposed to one or more substances linked to the
health effect, then the claim should be carefully reviewed to determine
whether, based upon the claimant’s documented job title and work activities,
there should be an industrial hygiene review to determine whether any significant
exposures to the material(s) in question may have occurred.

Example:The Cleveland
District Office receives the SEM Detail Report covering the period of
April through June 2008 (see Figure 1).

a. Using the SEM Detail
Report, select the “CLE” tab to display those cases that may need
reevaluation at the Cleveland District Office (see Figure 2). Delete the first
row of the spreadsheet and then enable the Excel Auto Filter feature for all
remaining columns and rows (see Figure 3).

b. Suppose the District
Office is interested in reviewing denied cases with the ICD-9 code of 173.3,
Skin Cancer. In the “ICD-9 CD” column, click on the drop-down arrow and select
“173.3”. The list of those denied cases linked to ICD-9 code 173.3 is returned
(see Figure 4).

c. Suppose the District
Office is interested in reviewing the denied ICD-9 code 173.3 at cases at [SITE
NAME], Worksite ID 242. In the “Worksite ID” column, select “242”. The list
of those denied cases linked to ICD-9 code 173.3 at the [SITE NAME] is returned.
Nine cases are listed (see Figure 5).

d.If
the District Office is interested in reviewing case #111111111, that number
should be highlighted off the spreadsheet (See Figure 6) and assigned to a
Claims Examiner who would then retrieve the case file. Using information from
the case file, the Claims Examiner repeats the SEM searches for case 111111111
that are applicable to Skin Cancer.

(1) If the SEM indicates
that none of the claimant’s potential exposures is related to skin cancer, then
document this information and return the case file.

(2) If the SEM indicates
that the worker may have been exposed to one or more substances linked to skin
cancer, then the claim should be carefully reviewed to determine whether, based
upon the claimant’s documented job title and work activities, there should be
an industrial hygiene review to determine whether any significant exposures to
the material(s) in question may have occurred.

2.Using
the Pre-Adjudication SEM Changes Report (in the SEM database): On the SEM Main Menu,
clicking on the link “Adjudication-Related Change Report” on the lower task bar
takes authorized users to a search page. That page allows the user to search
SEM for recent changes in the SEM diseases and disease associations that could
affect the recommended decision of a case that has been evaluated, but where a
final adjudication decision has not yet been made. The following search filters
are available:

·Site
name

·Health
effect

·Reporting
period

In addition, the user can select what features of
the search are displayed:

·Show
sites (shows all the sites affected by a change in a health effect during the
selected reporting period)

·Show
toxics (shows all the toxic substances associated with the health effect and
any changes - additions and deletions - in disease associations during the
selected reporting period)

·Show
dates (shows the date that a disease was added to SEM and the date(s) of any
disease association changes during the selected reporting period)

Because the SEM contains large amounts of data, the
user will find that search times are shorter if use of the above features is limited
to just those necessary. Selecting all the features will result in thousands
of rows of information being returned and will slow response time.

d. Select a start date just
after the SEM searches in the case file were completed, and select an end date
of yesterday. For example, if a case was researched in the SEM on June 28, 2008, and today’s date is December 5, 2008, then the reporting period should be June 29, 2008 to December 4, 2008.

e. Click “Run Report.” Within
the designated reporting period, the returned report tells the user whether the
selected disease was added, deleted, or had disease association changes.

f. If changes are reported,
then the case may need to be reevaluated using current SEM data before it is
adjudicated.

Example 1: “Worker C” worked at the Pinellas Plant from 1970
to 1990. He filed a COPD claim in July 2008. Case research was completed on August 15, 2008, and a recommended “denial” decision made. However, a final adjudication
decision has not been made. The user wants to know, “Have changes been made in
the SEM information for COPD that could affect the adjudication decision?” Assume
that today’s date is December 5, 2008.

e. Click “Run Report.”
Results: The returned information shows that no changes have been made in the
SEM COPD information at Pinellas since the denial recommendation was made on August 15, 2008 (see Figure 11). The SEM page with this information is printed and
inserted in the file and is processed for adjudication.

f. Since there were no
changes in COPD from the time the case was previously researched in the SEM,
there is no need for case reevaluation.

Example
2: “Worker
D” worked at Hanford from 1975 to 2001. He filed an “occupational asthma”
claim in July 2008. Case research was completed on August 15, 2008, and a recommended “denial” decision was made. However, a final adjudication decision has
not yet been rendered. The user wants to know, “Have changes been made in the
SEM information for occupational asthma that could affect the adjudication
decision?” Assume that today’s date is December 5, 2008.

a. Select “Changes Report” on the SEM Main Menu
lower task bar.

b. On the returned page, select “Hanford” as the
site (see Figure 12).

e. Click “Run Report”. Results: two rows of data
are returned (see Figure 15). This alerts the user that since August 15, 2008, changes (additions, deletions, or both) have occurred in the occupational
asthma toxic material associations.

f. Because there were changes in occupational asthma
associations since the time that the case was previously researched in the SEM,
there is a need for reevaluation.

Note
that this generated report can be used by authority granted at the discretion
of District Directors/FAB Managers or other management; ad hoc reports can also
be run as needed.

Disposition: Retain until incorporated
in the Federal EEOICPA Procedure Manual.